Post-transplant lymphoproliferative disorders (PTLD) are complications that arise from post-transplantation immunosuppressive therapy. Although Epstein-Barr virus (EBV) viremia is often seen in PTLD, it is not a definitive feature for diagnosis. We report a rare case of recurrent PTLD in a 26-year-old heart transplant recipient on high-dose tacrolimus who presented with emesis, fatigue, and bloody diarrhea. Although substantial EBV viremia was seen in the first PTLD episode, the current episode was a gastrointestinal manifestation with barely detectable circulating EBV. The patient's history of gastrointestinal disease delayed definitive diagnosis, which was later established through endoscopy and biopsy sample analysis.
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